Case Study of the Week: Radial Head Subluxation

I love a medical problem with an immediate fix.  The patient leaves happy, I feel the satisfaction of having made someone's day just a bit better.  It is much nicer to push, pull, feel a clunk and cure the issue at hand rather than inform your patient that unfortunately they are suffering from a viral infection and should plan on a few days of feeling under the weather.  That is why I love a good case of Radial Head Subluxation (Nursemaid's Elbow). 

Case Presentation

A mother presents to the emergency department with her three year-old child.  The mother and patient were playing at a local playground, the child began to trip so her mother grabbed the child's left arm to prevent a fall.  Since this time, the child has refused to use her left arm and winces when the arm is touched.  She holds the arm against her body in the flexed, adducted position.  

The child is in no acute distress, her vital signs are stable and you note no other signs of injury.  The child has full passive range of motion of the wrist and fingers and is mildly tender over the radial head.  You note no swelling or ecchymosis.  She is neurovascularly intact in the affected extremity.  X-Rays of the child's left elbow are normal.  Based on the history of injury you suspect radial head subluxation (Nursemaid's Elbow) and plan to reduce the subluxation.

Management and Outcome

The treatment for radial head subluxation is reduction.  This is a quick, easy procedure and does not require sedation.  Tylenol or Motrin may be administered for discomfort.  Beginning with the elbow flexed, place pressure on the radial head.  Supinate the wrist with the elbow still flexed the moving the hand upward, flex the elbow completely.  A click or clunk is often felt.  

Following reduction, check the neurovascular status of the affected arm.  The child should begin using the affected extremity almost immediately.  If the child still hesitates to use the injured arm, wait a few minutes for the child to calm and offer an activity such as a coloring book or a snack.  This may encourage the child to use the injured extremity. 

If the child does not begin to use the injured arm, the reduction may be attempted 2-4 more times at 15 minute intervals.  If ultimately unsuccessful, place the child in a posterior long arm splint and refer to an orthopedist for further evaluation and treatment.

Reduction of the radial head is typically free of complications.  27% of patients do experience recurrence of radial head subluxation.  In rare cases, surgical repair is necessary. 

Discussion

Radial head subluxation is the most common elbow injury in children typically occurring between the ages of one and four.  Girls are more commonly affected than boys.  Typically, the mechanism of injury involves a sudden pulling or jerking of the child's arm.  As this problem is easily fixed in the clinic or emergency department with reduction, it is important that nurse practitioners be able to diagnose and treat this condition.  As with any pediatric injury, the provider must consider and report child abuse if suspected.